Maple Grove Dental
6627 McKee Road
Madison, WI 53719
(608) 848-5680


Our Hours:

  • Monday :
  • 8:00AM - 2:00PM
  • Tuesday :
  • 8:00AM - 6:00PM
  • Wednesday :
  • 7:00AM - 5:00PM
  • Thursday :
  • 7:00AM - 4:00PM
  • Friday :
  • 7:00AM - 1:00PM




Dental History


Patient's Last Name:
First Name:
M.I.:
Date of Birth:

1. How long since your last dental visit?
2. What was done at that time?
3. Previous dentist's Information?
Name:
Address:
Phone:
4. Why have you scheduled today?
Check up: Dental pain: Other(explain):
5. When was the last time your teeth were cleaned?
6. Have you made regular dental visits?
Yes: No:
How Often?
7. Were dental x-rays taken at your last visit?
Yes: No:
8. Have you lost any teeth or have you had any teeth removed?
Yes: No:
Why?
9. Have they been replaced?
Yes: No:
If YES, Have they been replaced?
Implant (When)
Fixed Bridge (When)
Removable Appliance (When)
Denture (When)
If no, would you like to know about permanent replacements? Yes: No:
10. Are you unhappy with the replacement?
Yes: No:
Explain?
11. Have you ever had problems or complications with previous dental treatment?
Yes: No:
Explain?
12. Do you clench or grind your teeth?
Yes: No:
If yes, do you have/wear a guard at night or throughout the day? Yes: No:
13. Does your jaw pop or click?
Yes: No:
How Often?
14. Do you have pain or soreness in the muscles around your face or ear?
Yes: No:
How Often?
15. Does food get caught in your teeth?
Yes: No:
In what area?
16. Are your teeth sensitive to:
Hot: Cold: Pressure: Sweets:
17. Do your gums bleed or hurt?
Yes: No:
When?
18. How often do you brush your teeth?
When?
19. Do you use dental floss?
Yes: No:
How often?
20. Are you unhappy with the appearance of your teeth?
Yes: No:
Explain?
21. Is your breath offensive at times?
Yes: No:
When?
22. Have you ever had periodontal (gum) surgery?
Yes: No:
Where?
When?
23. Have you had orthodontic (braces or retainers) work?
Yes: No:
24. Do you have anything that you do not like about dental appointments?


Medical History


1. Medical Doctor?
Name:
Address:
Phone:
2. Are you under a physician's care at this time?
Yes: No:
Since when?
Why?
3. When was your last complete physical exam?
4. Are you taking any medications or health related substances?
Yes: No:
5. Do you have any allergies?
Yes: No:
Medications:
Environmental:
6. Do you use birth control medications?
Yes: No:
If yes, please list:
7. Are you pregnant or suspect you may be?
Yes: No:
Expected Due Date:
8. Do you have any problems with antibiotics, anesthetics or other medications?
Yes: No:
a. If yes, explain:
9. Do you react negatively to metals or latex?
Yes: No:
10. Do you have any of the following?

Pace maker : Artificial heart valve implant: Heart disease:
Rheumatic fever : Heart murmur:
Other:
11. Do you have high or low blood pressure?
Yes: No:
a. If yes, how is it controlled:
12. Have you ever had a major surgery or illness?
Yes: No:
a. If yes, explain:
13. Have you ever been treated with:

Radiation treatment : Chemotherapy treatment:
14. Do you have any artificial joints or prosthesis?
Yes: No:
a. If yes, explain:
15. Do you have any blood disorders such as anemia, leukemia, etc?
Yes: No:
a. If yes, explain:
16. Have you been diagnosed with:

GERD : Acid Reflux: Other stomach problems:
17. Do you have herpes or cold sores?
Yes: No:
a. If yes, how often?
18. Have had any problems or disorders with your liver?
Yes: No:
19. Do you have diabetes?
Yes: No:
If yes, Type I: or Type II:
20. Do you have asthma?
Yes: No:
If yes, Do you carry an inhaler? Yes: No:
21. Do you have epilepsy or seizure disorders?
Yes: No:
a. If yes, Date of last seizure?
22. Have you ever tested positive for HIV or AIDS?
Yes: No:
23. Have you had or do you test positive for hepatitis?
Yes: No:
If yes, A: B: C:
24. Do you have or have you ever tested positive for Tuberculosis (T.B.)?
Yes: No:
25. Do you use tobacco?
Yes: No:
a. If yes, How much?
b. How many years?
c. What form?
26. How many alcoholic beverages do you consume per week?

27. Do you use habitually controlled substances?
Yes: No:
If yes, when was the last time?
28. Have you been diagnosed with LD, ED, CD, ADHA or ADD?
Yes: No:
If yes, what is the best form for patient consultation? Verbal: Written:
29. Please list anything else not covered in this form that we should know about your health.